Provider Demographics
NPI:1659877967
Name:COSGROVE, COLEMAN KIDD
Entity Type:Individual
Prefix:
First Name:COLEMAN
Middle Name:KIDD
Last Name:COSGROVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 STAPLES CT
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-2195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:785 N DEAN RD STE 300
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830-4034
Practice Address - Country:US
Practice Address - Phone:334-734-5007
Practice Address - Fax:334-325-2306
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3043442084P0800X
390200000X
ALDO.27202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program